- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $174.27 / $174.27 / $258.26
| Facility | 26 | $174.27 | $174.27 | $258.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.25 / $177.00 / $817.00
| Professional | | $153.25 | $177.00 | $817.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.48 / $195.48 / $195.48
| Professional | | $195.48 | $195.48 | $195.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.71 / $164.94 / $179.38
| Professional | | $123.71 | $164.94 | $179.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.19 / $197.49 / $365.25
| Professional | | $150.19 | $197.49 | $365.25 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $212.19 / $420.63 / $420.63
| Facility | 26 | $212.19 | $420.63 | $420.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.50 / $178.00 / $1,321.58
| Professional | | $139.50 | $178.00 | $1,321.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.19 / $164.59 / $305.66
| Professional | | $139.19 | $164.59 | $305.66 |